Information Collection

Medical Record Abstraction

IC 236873 under ICR 201907-0906-001 · OMB 0906-0046.

Documents and Forms

Document Name Document Type
Form 3 Medical Record Abstraction Form and Instruction
3 Attachment C1 - Medical_Record_Abstraction_long.xlsm Attachment C1 - Medical_Record_Abstraction_long.xlsm Form and Instruction
4 Attachment C2 - Medical_Record_Astraction_short.xlsm Attachment C2 - Medical_Record_Astraction_short.xlsm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Record Abstraction	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Attachment C1 - Medical_Record_Abstraction_long.xlsm	Attachment C1 - Medical_Record_Abstraction_long.xlsm		Yes	Yes	Fillable Fileable
Form and Instruction	4	Attachment C2 - Medical_Record_Astraction_short.xlsm	Attachment C2 - Medical_Record_Astraction_short.xlsm		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 10

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.